Nursing Elites

1. The nurse is caring for a client who has a chest tube in place following a pneumothorax. The nurse notes that there is continuous bubbling in the water seal chamber of the chest tube drainage system. What action should the nurse take?

• A. Check for kinks in the tubing
• B. Notify the healthcare provider
• C. Replace the chest tube drainage system
• D. Reinforce the chest tube dressing

Correct answer: B

Rationale: The correct action for the nurse to take when observing continuous bubbling in the water seal chamber of the chest tube drainage system is to notify the healthcare provider. Continuous bubbling indicates a possible air leak, and the healthcare provider needs to be informed to assess the situation and take appropriate actions. Checking for kinks in the tubing (Choice A) may be done initially but is not the priority when continuous bubbling is present. Replacing the chest tube drainage system (Choice C) and reinforcing the chest tube dressing (Choice D) are not immediate actions needed in response to continuous bubbling in the water seal chamber.

2. While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement?

• A. Elevate the head of the client's bed
• B. Auscultate the client's breath sounds
• C. Measure the length of the apneic periods
• D. Suction the client's oropharynx

Correct answer: C

Rationale: When a nurse observes periods of apnea in a client experiencing Cheyne-Stokes respirations, measuring the length of the apneic periods is essential. This action helps in determining the severity of Cheyne-Stokes respirations by providing valuable information about the duration of interrupted breathing cycles. Elevating the head of the client's bed (Choice A) may be beneficial in some respiratory conditions but is not the priority in Cheyne-Stokes respirations. Auscultating the client's breath sounds (Choice B) is a general assessment and may not directly address the issue of apnea in Cheyne-Stokes respirations. Suctioning the client's oropharynx (Choice D) is not the initial intervention for managing Cheyne-Stokes respirations unless secretions are obstructing the airway.

3. A client with type 1 diabetes mellitus reports feeling shaky and has a blood glucose level of 60 mg/dl. What action should the nurse take?

• A. Administer 15 grams of carbohydrate
• B. Administer a glucagon injection
• C. Provide a snack with protein
• D. Encourage the client to rest

Correct answer: A

Rationale: The correct action for a client with type 1 diabetes mellitus experiencing hypoglycemia with a blood glucose level of 60 mg/dl is to administer 15 grams of carbohydrate. This will help raise the blood glucose levels quickly. Administering a glucagon injection (Choice B) is usually reserved for severe hypoglycemia where the client is unconscious or unable to swallow. Providing a snack with protein (Choice C) is not the first-line treatment for hypoglycemia as protein takes longer to raise blood glucose levels. Encouraging the client to rest (Choice D) may be beneficial after administering the carbohydrate, but the priority is to raise the blood glucose levels promptly.

4. While teaching a group of adults about health promotion activities, a nurse identifies a behavior that poses the most significant risk factor for the development of skin cancer. Which behavior should the nurse address?

• A. Consuming a high-fat diet
• B. Using tanning beds
• C. Smoking cigarettes
• D. Drinking alcohol

Correct answer: B

Rationale: Using tanning beds is the most significant risk factor for developing skin cancer. Ultraviolet (UV) radiation from tanning beds damages the skin and increases the risk of skin cancer. Consuming a high-fat diet, smoking cigarettes, and drinking alcohol are unhealthy behaviors but are not directly linked to the development of skin cancer like UV exposure from tanning beds.

5. The client is being taught how to take alendronate (Fosamax) for osteoporosis treatment. Which statement indicates that the client needs further teaching?

• A. I should take this medication at bedtime
• B. I will need to take this medication for at least 3 years
• C. I should sit up for 30 minutes after taking the medication
• D. I should take this medication with a full glass of water

Correct answer: A

Rationale: The correct answer is A because taking Fosamax at bedtime is incorrect. It should be taken in the morning with a full glass of water to prevent esophageal irritation. Choice B is correct; alendronate is typically taken for several years to treat osteoporosis. Choice C is correct as remaining upright for 30 minutes after taking Fosamax helps prevent esophageal irritation. Choice D is also correct as taking alendronate with a full glass of water is necessary to ensure proper absorption.

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